Title VI Complaint Form Cleveland Area Rapid Transit (CART)

Page 1 of 3 (10/15/12)
Title VI Complaint Form
Cleveland Area Rapid Transit
CART is committed to ensuring that no person is excluded from participation in or denied benefits of its services on the basis of race, color, or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days of the date of the alleged discrimination.
The following information is necessary to assist us in processing your complaint. If you require assistance in completing this form, please contact the Title VI Coordinator (405.325.2278). The completed complaint form must be signed and returned to: CART, Title VI Coordinator, 510 E. Chesapeake, Norman, OK 73019-5128. CART will send a written acknowledgement of the complaint within 10 working days.
Complainant Contact Information (Person Discriminated Against)
Name:
Mailing Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Email Address:
Person Discriminated Against (if someone other than complainant)
Name
Mailing Address:
City:
State:
Zip Code: Title VI Complaint Form
Cleveland Area Rapid Transit
Page 2 of 3 (10/15/12)
Incident Details
Which of the following best describes the reason for the alleged discrimination? Check all that apply.
Race
Color
National Origin (Limited English Proficiency)
Date of Incident (Month, Day, Year):
Time of incident:
Describe what happened and the alleged discrimination. Attach additional sheets if necessary.
Where did the incident take place? Include location, bus number, etc. Attach additional sheets if necessary.
Describe all persons involved and the person(s) responsible for the alleged discrimination. (Include names if known)
Title VI Complaint Form
Cleveland Area Rapid Transit
Page 3 of 3 (10/15/12)
Names and contact information of witnesses
Witness 1:
Day Phone:
Mailing Address
Evening Phone:
City:
State:
Zip Code:
Witness 2:
Day Phone:
Mailing Address
Evening Phone:
City:
State:
Zip Code:
Did you file this complaint with another federal, state or local agency? (Circle one) Yes/No
If yes, list the name of the agency (agencies) and contact information
Agency:
Contact Person:
Mailing Address:
Phone:
City:
State:
Zip Code:
Agency:
Contact Person:
Mailing Address:
Phone:
City:
State:
Zip Code:
I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
Signature and date are required. Attach any documents that support your complaint.
Complainant’s Signature
Signature Date
Date CART Received:
Date Received by Title VI Coordinator:
Signature:

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Page 1 of 3 (10/15/12)
Title VI Complaint Form
Cleveland Area Rapid Transit
CART is committed to ensuring that no person is excluded from participation in or denied benefits of its services on the basis of race, color, or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days of the date of the alleged discrimination.
The following information is necessary to assist us in processing your complaint. If you require assistance in completing this form, please contact the Title VI Coordinator (405.325.2278). The completed complaint form must be signed and returned to: CART, Title VI Coordinator, 510 E. Chesapeake, Norman, OK 73019-5128. CART will send a written acknowledgement of the complaint within 10 working days.
Complainant Contact Information (Person Discriminated Against)
Name:
Mailing Address:
City:
State:
Zip Code:
Day Phone:
Evening Phone:
Email Address:
Person Discriminated Against (if someone other than complainant)
Name
Mailing Address:
City:
State:
Zip Code: Title VI Complaint Form
Cleveland Area Rapid Transit
Page 2 of 3 (10/15/12)
Incident Details
Which of the following best describes the reason for the alleged discrimination? Check all that apply.
Race
Color
National Origin (Limited English Proficiency)
Date of Incident (Month, Day, Year):
Time of incident:
Describe what happened and the alleged discrimination. Attach additional sheets if necessary.
Where did the incident take place? Include location, bus number, etc. Attach additional sheets if necessary.
Describe all persons involved and the person(s) responsible for the alleged discrimination. (Include names if known)
Title VI Complaint Form
Cleveland Area Rapid Transit
Page 3 of 3 (10/15/12)
Names and contact information of witnesses
Witness 1:
Day Phone:
Mailing Address
Evening Phone:
City:
State:
Zip Code:
Witness 2:
Day Phone:
Mailing Address
Evening Phone:
City:
State:
Zip Code:
Did you file this complaint with another federal, state or local agency? (Circle one) Yes/No
If yes, list the name of the agency (agencies) and contact information
Agency:
Contact Person:
Mailing Address:
Phone:
City:
State:
Zip Code:
Agency:
Contact Person:
Mailing Address:
Phone:
City:
State:
Zip Code:
I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
Signature and date are required. Attach any documents that support your complaint.
Complainant’s Signature
Signature Date
Date CART Received:
Date Received by Title VI Coordinator:
Signature: